AHIP AHIP Certifications AHM-540 Questions & Answers

• Question 141:

  Patricia McLeod is a member of the Enterprise Health Plan, which operates in State X. Ms. McLeod is scheduled to undergo a unilateral mastectomy for the treatment of breast cancer. The surgical procedure will be performed by Dr. Kim Lee, a surgical oncologist. Based on Enterprise's medical policy, the contract with the purchaser, and Ms. McLeod's medical condition, Enterprise's UR staff have determined that the appropriate course of care for Ms.

  McLeod includes a 24-hour stay in the hospital following her surgery. State X, however, has a benefit mandate specifying health plan coverage for 48 hours of inpatient post- mastectomy care. In this situation, the length of hospital stay for which Enterprise must offer coverage is

  A. the length of stay deemed appropriate by Dr. Lee

  B. the 24-hour stay determined to be appropriate by Enterprise's UR staff

  C. the length of stay deemed appropriate by Ms. McLeod

  D. the 48-hour length of stay specified by State X

  Correct Answer: D

• Question 142:

  In order to achieve changes in outcomes, health plans make changes to existing structures and processes. The introduction of preauthorization as an attempt to control overuse of services is an example of a reactive change. Reactive changes are typically

  A. both planned and controlled

  B. planned, but they are rarely controlled

  C. controlled, but they are rarely planned

  D. neither planned nor controlled

  Correct Answer: C

• Question 143:

  Increased demands for performance information have resulted in the development of various health plan report cards. With respect to most of the report cards currently available, it is correct to say

  A. that they are focused primarily on health maintenance organization (HMO) plans

  B. that they are based on data collected for the Health Plan Employer Data and Information Set (HEDIS)

  3.0

  C. that they are used to rank the performance of various health plans

  D. all of the above

  Correct Answer: D

• Question 144:

  Comparing the quality of managed Medicare programs with the quality of FFS Medicare programs is often difficult. Unlike FFS Medicare, managed Medicare programs

  A. can measure and report quality only at the provider level

  B. use a single system to deliver services to all plan members

  C. provide an organizational focus for accountability

  D. can use the same performance measures for all products and plans

  Correct Answer: C

• Question 145:

  Most health plans require a PCP referral or precertification for CAM benefits.

  A. True

  B. False

  Correct Answer: B

• Question 146:

  The Riverside Health Plan is considering the following provider compensation options to use in its contracts with several provider groups and hospitals:

  1.

  A discounted fee-for-service (DFFS) payment system

  2.

  A case rate system

  3.

  Capitation

  If Riverside wants to use only those compensation methods that encourage the efficient use of resources, then the compensation method(s) that Riverside should consider for its new contracts include

  A. 1, 2, and 3

  B. 1 and 2 only

  C. 2 and 3 only

  D. 3 only

  Correct Answer: C

• Question 147:

  The following statement(s) can correctly be made about performance measurement systems:

  1.The most difficult purpose for a performance measurement system to address is to measure changes in outcomes caused by modifications in administrative or clinical treatment processes

  2.A

  health plan needs different performance measurement systems to evaluate its administrative services and the clinical performance of its providers

  A.

  Both 1 and 2

  B.

  1 only

  C.

  2 only

  D.

  Neither 1 nor 2

  Correct Answer: C

• Question 148:

  Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans typically use home healthcare include

  1.The period prior to a hospital admission

  2.The period following discharge from a hospital

  A. Both 1 and 2

  B. 1 only

  C. 2 only

  D. Neither 1 nor 2

  Correct Answer: A

• Question 149:

  Designing effective medical management programs for Medicare beneficiaries requires an understanding of the unique health needs of the Medicare population. One characteristic of Medicare beneficiaries is that they typically

  A. do not experience mental health problems

  B. consume more than half of all prescription drugs

  C. are likely to equate quality with the technical aspects of clinical procedures

  D. require longer and more costly recovery periods following acute illnesses or injuries than does the general population

  Correct Answer: D

• Question 150:

  The following statements are about disease management programs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

  A. The focus of disease management is on responding to the needs of individual members for extensive, customized healthcare supervision.

  B. Disease management programs serve to improve both clinical and financial outcomes for healthcare services related to chronic conditions.

  C. Tools such as preventive care, self-care, and decision support programs are used to support both case management and disease management.

  D. Disease management programs apply to both diseases and medical conditions that are not diseases, such as high-risk pregnancy, severe burns, and trauma.

  Correct Answer: A